Ineffective Drainage Research Articles

Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access

In this prospective case series, endoscopic management of pancreatic pseudocysts and abscesses was investigated following an EUS-guided 1-step procedure for initial transmural access. Endoscopic drainage of pancreatic pseudocysts and abscesses was performed in 35 patients (mean age, 51 years; range, 21-81 years) by using interventional echoendoscopes (FG38UX and EG3830UT; Pentax-Hitachi, Lübbecke, Germany). Interventions were performed by using a 1-step device consisting of a needle-wire suitable for cutting current, a 5.5F dilator, and an 8.5F plastic endoprosthesis (Giovannini Needle Wire Oasis, Cook Endoscopy, Winston-Salem, NC). Endoscopic stent placement was successful in 33 of 35 patients (94%), whereas repeated needle passages were unsuccessful in 2 cases (pancreatic pseudocyst wall, 7 mm). No procedure-related complications, such as bleeding, perforation, or pneumoperitoneum, were observed. All subsequent complications, such as ineffective drainage (9%), stent occlusion (12%), or cyst infection (12%), were managed endoscopically. Fourteen patients (43%) demonstrated sustained clinical improvement and cyst resolution upon placement of the initial 8.5F transmural drain. Ten patients (30%) did not reveal a 50% reduction in cyst size on day 3, but cyst resolution was achieved by additional endoscopic cyst irrigation. Nine patients (27%) with primary or secondary cyst infection underwent endoscopic balloon dilation and prolonged endoscopic drainage procedures to achieve cyst resolution. The overall resolution rate was 88%, with a recurrence rate of 12%, based on a mean follow-up period of 24 months. This 1-step EUS-guided technique with a needle-wire device provides safe transmural access and allows subsequent effective endoscopic management of pancreatic pseudocysts and abscesses.

Surgical Drainage of Late Cardiac Tamponade Following Open Heart Surgery

There are few reports on postoperative late cardiac tamponade with surgical therapy in the literature. Hospital records of 87 patients with postoperative late cardiac tamponade who had undergone cardiac surgery between January 1999 and December 2003 were evaluated retrospectively. Out of 8400 patients who had undergone cardiac surgery, 87 patients (1 %) had postoperative late cardiac tamponade. The incidence was 0.1 % for patients with coronary artery bypass grafting and 3.4 % for those with heart valve replacement ( p < 0.01). Subxiphoid midline incision was carried out in 67 patients (77 %). Conversion to re-sternotomy was required in 8 patients due to either ineffective drainage (5 patients, 7.5 %) or laceration and bleeding (3 patients, 4.5 %). Re-sternotomy was undertaken in 20 patients with no complication. Early death occurred in 3 patients with subxiphoid drainage (3.5 %), two of which were related to bleeding. Out of 84 patients who survived, 10 patients had recurrent cardiac tamponade, 5 of which required surgical drainage (6 %). Bleeding due to dense adhesions between the epicardium and the sternum may be encountered during subxiphoid drainage for postoperative late cardiac tamponade and lead to a 3 % mortality rate.

Drop foot after high tibial osteotomy: a prospective study of aetiological factors.

Drop foot is not uncommon after high tibial osteotomy for genu varum. The authors report their results of a prospective study of 16 patients operated on between May 1990 and May 1991. All patients had medial femoro-tibial osteoarthritis with a constitutional genu varum. They all had a subtraction valgus high tibial osteotomy fixed by a blade plate. The experimental protocol included clinical review, antero-lateral compartment pressure measurements, intra- and post-operative electromyography, assessment of the post-operative drainage, serum estimation of muscle enzymes and post-operative arteriography. From their own results and a literature review, the authors consider successively the different aetiological factors for post-operative drop foot. Certain deficits occur due to direct trauma on the nerve during high osteotomy of the fibula, by local high pressure due to poor haemostasis or ineffective drainage. In addition, there are several related phenomena. The pneumatic tourniquet sensitises the nerve to trauma, and stretching of the nerve during correction of the deformation depends on the local anatomical factors and their marked variation. In order to diminish the frequency of these post-operative complications, the authors suggest limiting the surgical approach, and limiting as far as possible the traumatic manoeuvres on the nerve by using a tibial resection jig, which allows correction without forced manoeuvres. Finally, the authors discuss the benefits of using a pneumatic tourniquet.

Antiperistaltic Roux-en-Y Biliary-Enteric Bypass after Bile Duct Injury: A Technical Error in Reconstruction

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

Endoscopic sphincterotomy in patients with liver cirrhosis

Background: Nonsurgical alternatives in biliary diseases have not been studied in large series of patients with cirrhosis. Our aim was to determine the indications and results of endoscopic treatment in this subset of patients.Methods: Fifty-two patients (36 men, 16 women—Child-Pugh Class A, 18; B, 22; C, 12) aged 63 ± 18 years underwent endoscopic sphincterotomy (ES) between 1988 and 1993. Antibiotic prophylaxis was routinely carried out and coagulopathy was corrected before ES when required. The data were collected retrospectively up to 30 days after ES.Results: ES succeeded in 98% of the patients (12 cases of needle-knife papillotomy). Twenty-nine patients (55.7%) had choledocholithiasis, 18 had biliary strictures (12 malignant), and 5 had pancreatic or other biliary diseases. Five days after ES, morbidity was 13.5% and mortality was 7.7%. At 1 month, morbidity was 22.9% and mortality 12.5%. Only endoscopic procedures and ineffective drainage were seen to be significant risk factors of morbidity. The results of the subgroup of cirrhotic patients with choledocholithiasis (n = 29) were compared with those of matched noncirrhotic patients (n = 58). The cirrhotic and noncirrhotic patients treated for choledocholithiasis showed similar results for stone clearance, morbidity, and mortality.Conclusion: ES is a safe and effective procedure for treating choledocholithiasis in cirrhotic patients. ES can therefore be considered as an alternative to surgery in Child class A and B patients and must be preferred for Child class C patients with life-threatening biliary complications. (Gastrointest Endosc 1996;43:127-31.)